Surveillance For Lyme Disease After Implementation of A Revised Case Definition - United States, 2022

Morbidity and Mortality Weekly Report
Weekly / Vol. 73 / No. 6 February 15, 2024
Surveillance for Lyme Disease After Implementation of a Revised

Case Definition — United States, 2022
Kiersten J. Kugeler, PhD1; Austin Earley, MPH1; Paul S. Mead, MD1; Alison F Hinckley, PhD1
Abstract relies almost exclusively on serologic testing for antibodies to

Lyme disease, a tickborne zoonosis caused by certain species of B. burgdorferi using a two-tier process (1).
Borrelia spirochetes, is the most common vectorborne disease in Before 2022, national surveillance for Lyme disease required
the United States. Approximately 90% of all cases are reported the collection of clinical information, most often coupled
from 15 high-incidence jurisdictions in the Northeast, mid- with laboratory evidence of infection, to classify cases. As the
Atlantic, and upper-Midwest regions. After the implementation number of Lyme disease infections has increased, the workload
of a revised surveillance case definition in 2022, high-incidence associated with collecting clinical information has proven
jurisdictions report cases based on laboratory evidence alone, prohibitive in several high-incidence jurisdictions, leading to
without need for additional clinical information. In 2022, the adoption of modified, jurisdiction-specific surveillance
62,551 Lyme disease cases were reported to CDC, 1.7 times practices, including in New York and Massachusetts (2, 4–6).
the annual average of 37,118 cases reported during 2017–2019. These divergent approaches often precluded the reporting of
Annual incidence increased most in older age groups, with cases to CDC and prevented accurate comparison of trends
incidence among adults aged ≥65 years approximately double across jurisdictions and over time (3,7).
that during 2017–2019. The sharp increase in reported Lyme To address this challenge, effective January 1, 2022, the
disease cases in 2022 likely reflects changes in surveillance meth- Council of State and Territorial Epidemiologists (CSTE), in
ods rather than change in disease risk. Although these changes partnership with CDC, revised the national surveillance case
improve standardization of surveillance across jurisdictions, they definition for Lyme disease.† The revised case definition provides
preclude detailed comparison with historical data. for reporting of cases from high-incidence jurisdictions based
on laboratory evidence alone, without the need to collect addi-
Introduction tional clinical information. Cases reported from low-incidence
Lyme disease is a tickborne infection caused by spirochetes † https://ndc.services.cdc.gov/conditions/lyme-disease/
in the Borrelia burgdorferi sensu lato complex (1,2). Signs and
symptoms of early disease include erythema migrans, a red,
expanding rash often with central clearing, as well as fever and
INSIDE
fatigue. Untreated infection can disseminate, affecting the heart,
joints, and nervous system (1). National surveillance for Lyme 124 Routes of Drug Use Among Drug Overdose Deaths —
United States, 2020–2022
disease in the United States began in 1991 and has documented
131 Hepatitis A Exposure Response and Outbreak
a steady increase in incidence and geographic range. A majority
Prevention in a Large Urban Jail — Los Angeles
of cases of Lyme disease are reported from 15 high-incidence
County, California, May–July 2023
jurisdictions (those reporting at least 10 confirmed cases per
135 Notes from the Field: Long COVID Prevalence
100,000 population for 3 years) located in the Northeast, mid- Among Adults — United States, 2022
Atlantic, and upper-Midwest regions* (3). Laboratory diagnosis
137 QuickStats
* As of 2022, high-incidence jurisdictions are Connecticut, Delaware, District
of Columbia, Maine, Maryland, Massachusetts, Minnesota, New Hampshire,
Continuing Education examination available at
New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, West
Virginia, and Wisconsin.
https://www.cdc.gov/mmwr/mmwr_continuingEducation.html
U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
jurisdictions still require supporting clinical information, reviewed by CDC, deemed not research, and was conducted
although probable case classification criteria have been updated consistent with applicable federal law and CDC policy.**
to only include those patients with objective signs of infection.
This report summarizes the first year of Lyme disease surveillance Results
data collected using the 2022 case definition and compares these Overall: 2022 Versus 2017–2019
data to cases reported during 2017–2019.
After implementation of a revised Lyme disease case defini-
tion, a total of 62,551 Lyme disease cases were reported to
Methods
CDC in 2022 (including 59,734 from high-incidence juris-
Lyme disease cases are classified by state and local health dictions and 2,817 from low-incidence jurisdictions).†† This
departments according to CSTE surveillance case definitions finding represented an overall 68.5% increase from the annual
and reported to CDC through the Nationally Notifiable average of 37,118 cases reported during 2017–2019, including
Diseases Surveillance System.§ Because of reporting anomalies a 72.9% increase in high-incidence jurisdictions and a 10.0%
related to the COVID-19 pandemic (2020–2021) (8), cases increase in low-incidence jurisdictions (Table). During 2022,
reported in 2022 were compared with those reported during 95.5% of reported cases were reported from high-incidence
2017–2019. 2020 U.S. Census Bureau data were used as popula- jurisdictions, compared with an average of 93.1% during
tion denominators for incidence calculations.¶ Several reporting 2017–2019. Lyme disease incidence in 2022 (18.9 cases per
dates were used to compare trends in seasonality. For the years 100,000 population) was 68.8% higher than that during
2017–2019, illness onset date was used, whereas for 2022, illness 2017–2019 (11.2). In 2022, median incidence among high-
onset date, diagnosis date, laboratory test date, and date of labora- incidence jurisdictions (68.3 cases per 100,000) was 58%
tory report to health department were used. Data were analyzed higher than that during 2017–2019 (43.3), although median
using SAS software (version 9.4; SAS Institute). This activity was incidence among low-incidence jurisdictions (0.52 cases per
§ https://www.cdc.gov/nndss/index.html
100,000) was 24% lower than during 2017–2019 (0.68).
¶ https://data.census.gov/table?q=Age+and+Sex&t=Populations+and+
People&g=010XX00US&d=DEC+Demographic+and+Housing+ ** 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d);
Characteristics&tid=DECENNIALDHC2020.P12; https://data.census.gov/ 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
†† 2022 data from the National Notifiable Diseases Surveillance System. Interim
table?g=010XX00US$0400000&tid=PEPPOP2019.PEPANNRES
data as of February 13, 2023, before finalization and publication by CDC’s
Office of Public Health Data, Surveillance, and Technology.
The MMWR series of publications is published by the Office of Science, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human
Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2024;73:[inclusive page numbers].
Centers for Disease Control and Prevention
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119
US Department of Health and Human Services | Centers for Disease Control and Prevention | MMWR | February 15, 2024 | Vol. 73 | No. 6
TABLE. Number of reported Lyme disease cases and Lyme disease incidence, by jurisdiction and incidence category* — United States, 2017–2019
and 2022
No. of reported cases† Incidence§
Jurisdiction 2017–2019¶ 2022 Percent change** 2017–2019¶ 2022 Incidence difference††
High-incidence jurisdictions*
Connecticut 1,714 2,022 18.0 47.5 56.1 8.5
Delaware 590 298 −49.5 59.6 30.1 −29.5
District of Columbia 88 77 −12.5 12.7 11.2 −1.5
Maine 1,807 2,653 46.8 132.7 194.7 62.1
Maryland 1,563 2,035 30.2 25.3 32.9 7.6
Massachusetts 144 5,052 3,408.3 2.1 71.9 69.8
Minnesota 1,796 2,685 49.5 31.5 47.1 15.6
New Hampshire 1,506 1,085 −28.0 109.4 78.8 −30.6
New Jersey 4,237 5,897 39.2 45.6 63.5 17.9
New York 4,345 16,798 286.6 21.5 83.2 61.6
Pennsylvania 10,369 8,413 −18.9 79.7 64.7 −15.0
Rhode Island 1,071 2,326 117.2 97.6 212.0 114.3
Vermont 911 1,312 44.0 141.6 204.0 62.4
Virginia 1,332 1,403 5.3 15.4 16.3 0.8
West Virginia 735 2,470 236.1 41.0 137.7 96.7
Wisconsin 2,349 5,208 121.7 39.9 88.4 48.5
Subtotal 34,557 59,734 72.9 43.3 68.3 25.0
Low-incidence jurisdictions*
Alabama 48 32 −33.3 1.0 0.6 −0.3
Alaska 8 7 −12.5 1.1 1.0 −0.1
Arizona 15 9 −40.0 0.2 0.1 −0.1
Arkansas 9 2 −77.8 0.3 0.1 −0.2
California 131 77 −41.2 0.3 0.2 −0.1
Colorado 5 10 100.0 0.1 0.2 0.1
Florida 180 233 29.4 0.8 1.1 0.2
Georgia 15 31 106.7 0.1 0.3 0.2
Hawaii NR NR — NR NR —
Idaho 14 10 −28.6 0.8 0.5 −0.2
Illinois 315 259 −17.8 2.5 2.0 −0.4
Indiana 162 236 45.7 2.4 3.5 1.0
Iowa 280 154 −45.0 8.8 4.8 −4.0
Kansas 35 9 −74.3 1.2 0.3 −0.9
Kentucky 21 72 242.9 0.5 1.6 1.1
Louisiana 8 5 −37.5 0.2 0.1 −0.1
Michigan 322 557 73.0 3.2 5.5 2.3
Mississippi 3 3 0 0.1 0.1 0
Missouri 13 7 −46.2 0.2 0.1 −0.1
Montana 9 13 44.4 0.8 1.2 0.4
Nebraska 13 9 −30.8 0.7 0.5 −0.2
Nevada 16 10 −37.5 0.5 0.3 −0.2
New Mexico 4 3 −25.0 0.2 0.1 −0.1
North Carolina 280 279 −0.4 2.7 2.7 0
North Dakota 42 22 −47.6 5.4 2.8 −2.6
Ohio 343 553 61.2 2.9 4.7 1.8
Oklahoma 0 0 0 0 0 0
Oregon 73 61 −16.4 1.7 1.4 −0.3
South Carolina 36 44 22.2 0.7 0.9 0.2
South Dakota 10 12 20.0 1.1 1.4 0.3
Tennessee 40 32 −20.0 0.6 0.5 −0.1
Texas 49 23 −53.1 0.2 0.1 −0.1
Utah 24 16 −33.3 0.7 0.5 −0.2
Washington 33 23 −30.3 0.4 0.3 −0.1
Wyoming 3 4 33.3 0.5 0.7 0.2
Subtotal 2,561 2,817 10.0 0.7 0.5 −0.2
U.S. total 37,118§§ 62,551 68.5 11.2 18.9 7.7

See table footnotes on the next page.
120
TABLE. (Continued) Number of reported Lyme disease cases and Lyme disease incidence, by jurisdiction and incidence category* — United
States, 2017–2019 and 2022
Abbreviation: NR = not reportable.
* High-incidence jurisdictions are defined as jurisdictions reporting 10 or more confirmed cases per 100,000 population for 3 years. All other jurisdictions are low incidence.
† Lyme disease surveillance case definitions are available at https://ndc.services.cdc.gov/conditions/lyme-disease/. Case counts reflect the total number of cases
(confirmed and probable).
§ Incidence is defined as the number of cases per 100,000 population according to 2020 U.S. Census Bureau data. Subtotal incidence figures reflect median incidence
across jurisdictions in each incidence category.
¶ Cases and incidence during 2017–2019 reflect the 3-year annual average.
** Percent change in the number of cases reported during 2022 versus 2017–2019.
†† Incidence difference = (incidence in 2022 – 3-year average incidence during 2017–2019).
§§ Because of rounding of the average number of cases per jurisdiction, the total in the individual jurisdiction rows does not sum to the national 2017–2019 average.
Sex and Age of Lyme disease for the probable case classification in these
Males accounted for the majority of cases during 2017–2019 areas with lower disease risk.
(57.7%) and 2022 (57.3%). The age distribution was bimodal The relative increase in Lyme disease incidence in 2022 was
during both periods, but a larger percentage of reported cases larger among older age groups, with age-specific incidences
occurred among adults in 2022 than did during 2017–2019 more than doubling among adults aged ≥65 years relative to
(Figure 1). Among persons aged 5–9 years, incidence during those during 2017–2019. The differential increase in incidence
2022 (16.5 cases per 100,000) was 11.5% higher than the might reflect 1) more frequent laboratory testing among older
2017–2019 average (14.8). Among adults aged 75–79 years, age groups, 2) proportionally more disseminated illness in
incidence during 2022 (38.3) was 2.2 times the average during older age groups, and 3) proportionally more positive labora-
2017–2019 (17.3) (Figure 1). tory test results related to previous exposure to B. burgdorferi
rather than a current illness.
Illness Onset and Other Available Dates Date of illness onset is rarely available in high-incidence
Illness onset date was available for more than two thirds jurisdictions given reliance on laboratory-based reporting
(67.8% [75,491 of 111,354]) of cases reported during 2017– without case investigation to ascertain clinical information.
2019, but only 4.8% (2,987 of 62,551) of cases in 2022. Illness Alternative dates related to laboratory testing or reporting still
onset peaked during calendar week 26 during both 2017–2019 demonstrate summer seasonality, but are shifted 2 weeks later,
and 2022; however, in 2022, the diagnosis, laboratory test, reflecting the expected time lag required after symptom onset
and reporting dates peaked 2 weeks later (week 28) (Figure 2). to mount a detectable immune response to B. burgdorferi (1).
Discussion Limitations
After implementation of a revised surveillance case defini- The findings in this report are subject to at least two limita-
tion in 2022, the number of reported Lyme disease cases in tions. First, surveillance for Lyme disease is subject to under-
the United States increased 68.5% over the average reported and overreporting. Despite an increase in reported cases in
during 2017–2019; in high-incidence jurisdictions, the 2022, it is likely that current surveillance does not capture
number of cases increased 72.9%, whereas in low-incidence all cases of Lyme disease, specifically cases of early disease for
jurisdictions, the number of cases increased 10.0%. This which diagnosis is based on clinical findings alone, including
change reflects a large increase in the number of cases reported presence of erythema migrans rash, and laboratory evidence
from high-incidence jurisdictions on the basis of laboratory is lacking because of insufficient elapsed time to mount a
evidence alone. Before 2022, many of these cases would have detectable antibody response. Previous case definitions relied
been excluded, either because health departments were unable on direct clinician report to identify such cases; however, the
to obtain the necessary clinical information or because avail- frequency of such reporting was highly variable among high-
able clinical data were inconsistent with the objective criteria incidence jurisdictions (6). Conversely, reporting based solely
specified in the case definition. The increases in incidence in on serologic testing might result in the inclusion of clinically
2022 compared with 2017–2019 are particularly large among incompatible or nonincident cases (i.e., a positive laboratory
high-incidence jurisdictions that had previously modified Lyme test result based on previous infection). Antibody titers remain
disease surveillance practice to minimize the case investigation elevated for months to years after treatment for Lyme disease,
workload. The total number of cases in many low-incidence and asymptomatic seroconversion is also known to occur (1).
jurisdictions decreased, presumably because of changes in the In these instances, testing for Lyme disease when another eti-
2022 case definition requiring objective signs and symptoms ology is responsible for the current illness might generate an
121
FIGURE 1. Reported Lyme disease incidence (A) and the ratio of the 2022 incidence to the average 2017–2019 incidence (B), by sex and 5-year
age group — United States, 2017–2019 and 2022
A. Incidence B. Ratio of 2022 incidence to 2017–2019 incidence
Ratio of 2022 incidence to 2017–2019 incidence

50 3.0
45 Males 2017–2019 Males

Males 2022 2.5 Females
Cases per 100,000 population
40
Females 2017–2019 Identical incidence between
35 Females 2022 the two periods
2.0
30
25 1.5
20
1.0
15
10
0.5
5
0 0.0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
5-year age group 5-year age group
FIGURE 2. Week of illness onset or laboratory test and reporting date for reported Lyme disease cases* — United States, 2017–2019 and 2022
100
8 Illness onset 2017–2019

Illness onset 2022
Lab test and reporting 2022
7
Percentage of total
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52
Week
* Week 1 begins on the first Sunday of the calendar year.
erroneous case report. Second, changes in laboratory testing Lyme disease in 2019§§ (9). These assays have higher sensitivity
between the two analysis periods might have influenced Lyme in early illness than do standard algorithms and might have
disease incidence. The Food and Drug Administration cleared
§§
the first modified two-tier test (MTTT) serologic assays for https://www.aphl.org/aboutAPHL/publications/Documents/ID-2021-Lyme-
Disease-Serologic-Testing-Reporting.pdf
122
Acknowledgments
Summary
Vectorborne disease surveillance coordinators in state and local
What is already known about this topic?
health departments.
Lyme disease is the most common vectorborne disease in the
Corresponding author: Kiersten J. Kugeler, kkugeler@cdc.gov.
United States, but risk is geographically focal. After the imple-
mentation of a revised surveillance case definition in 2022, 1Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic
high-incidence jurisdictions report cases based on laboratory Infectious Diseases, CDC.
evidence alone, without the need for case investigation to
obtain clinical information. All authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of potential
What is added by this report?
conflicts of interest. No potential conflicts of interest were disclosed.
In 2022, reported case counts were 1.7 times the annual U.S.
average during 2017–2019. The relative change in incidence in References
2022 increased with patient age.
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123
Routes of Drug Use Among Drug Overdose Deaths — United States, 2020–2022
Lauren J. Tanz, ScD1; R. Matt Gladden, PhD1; Amanda T. Dinwiddie, MPH1; Kimberly D. Miller, MPH1; Dita Broz, PhD2;
Eliot Spector, MS1,3; Julie O’Donnell, PhD1
Abstract to smoking IMFs; however, limited data exist on recent changes

Preliminary reports indicate that more than 109,000 drug in routes of drug use for all drugs, and for IMFs beyond the
overdose deaths occurred in the United States in 2022; nearly western United States† (3,4). Routes of drug use have implica-
70% of these involved synthetic opioids other than metha- tions for overdose risk, infectious disease transmission, other
done, primarily illegally manufactured fentanyl and fentanyl comorbidities, and harm reduction services (5).
analogs (IMFs). Data from the western United States suggested
a transition from injecting heroin to smoking IMFs. CDC Methods
analyzed data from the State Unintentional Drug Overdose Jurisdictions entered data from death certificates, post-
Reporting System to describe trends in routes of drug use in mortem toxicology testing, and medical examiner or coroner
27 states and the District of Columbia among overdose deaths reports on unintentional and undetermined intent drug over-
that occurred during January 2020–December 2022, overall dose deaths into CDC’s State Unintentional Drug Overdose
and by region and drugs detected. From January–June 2020 Reporting System (SUDORS).§ Routes of drug use were
to July–December 2022, the percentage of overdose deaths identified using information from scene investigations, witness
with evidence of injection decreased 29.1%, from 22.7% to reports, or autopsy data and were categorized into nonmutually
16.1%, whereas the percentage with evidence of smoking exclusive categories of ingestion,¶ injection,** smoking,†† and
increased 73.7%, from 13.3% to 23.1%. The number of deaths snorting§§; other routes (e.g., transdermal) are not presented
with evidence of smoking increased 109.1%, from 2,794 to because sample sizes were small. Among 28 jurisdictions¶¶
5,843, and by 2022, smoking was the most commonly docu- with complete data,*** numbers and percentages of overdose
mented route of use in overdose deaths. Trends were similar
†
in all U.S. regions. Among deaths with only IMFs detected, https://adai.uw.edu/wordpress/wp-content/uploads/dlm_uploads/
FentanylQualitativeReport2023.pdf
the percentage with evidence of injection decreased 41.6%, § https://www.cdc.gov/drugoverdose/fatal/sudors.html
from 20.9% during January–June 2020 to 12.2% during ¶ Evidence of ingestion included witness reports of taking pills or tablets orally
July–December 2022, whereas the percentage with evidence or ingesting liquid orally (e.g., liquid methadone), or the discovery of
prescription pills, prescription bottles, liquid substances, or vials for containing
of smoking increased 78.9%, from 10.9% to 19.5%. Similar liquid substances at the scene of the overdose or on the decedent’s body.
trends were observed among deaths with both IMFs and ** Evidence of injection included witness reports of injecting drugs, items used
stimulants detected. Strengthening public health and harm to prepare and inject substances found at the scene (e.g., needles, cookers,
filters, tourniquets, or alcohol pads), or track marks found on the decedent
reduction services to address overdose risk related to diverse that appeared to be recent.
routes of drug use, including smoking and other noninjection †† Evidence of smoking included witness reports of smoking drugs or drug
paraphernalia at the overdose scene associated with smoking (e.g., pipes,
routes, might reduce drug overdose deaths. stems, aluminum foil, vape pens, matches, disposable lighters, or gas torches).
Fewer than 6.0% of deaths with evidence of smoking had vape pens or
Introduction e-cigarettes endorsed as evidence; fewer than 3.0% had vape pens or
e-cigarettes endorsed with no other evidence of smoking.
Preliminary data indicate that U.S. drug overdose deaths §§ Evidence of snorting included witness reports of snorting drugs, drug
surpassed 109,000 in 2022; nearly 70% of these deaths paraphernalia at the overdose scene associated with snorting (e.g., razor blades
or credit cards used to chop and separate powder; straws, rolled paper, dollar
involved synthetic opioids other than methadone, primarily bills, or tubes for nasal inhalation; or powder visible on a table or mirror),
illegally manufactured fentanyl and fentanyl analogs (IMFs).* or powder on the decedent’s nose.
¶¶ Alaska, Arizona, Colorado, Connecticut, Delaware, District of Columbia,
In recent years, deaths co-involving IMFs and stimulants have
Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts,
increased steadily (1). The estimated number of U.S. adults Minnesota, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio,
who inject drugs increased from approximately 774,000 in Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia,
2011 to nearly 3.7 million in 2018, corresponding to shifts Washington, and West Virginia. Illinois and Washington reported deaths
from counties that accounted for ≥75% of drug overdose deaths in the
from prescription opioid misuse to the use of heroin and IMFs respective state in 2017, per SUDORS funding requirements; all other
(2). More recent data suggest transitions from injecting heroin jurisdictions reported deaths from the full jurisdiction.
*** Jurisdictions were included if medical examiner or coroner reports and
toxicology reports were available for ≥75% of deaths during January 2020–
* https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (Accessed December 2022. Analyses were restricted to decedents with an available
January 11, 2024). medical examiner or coroner report (139,740; 95.8% of all deaths).
124
deaths were calculated by route of drug use and by 6-month The leading route of use in drug overdose deaths changed
period during January 2020–December 2022, overall, and from injection during January–June 2020 (22.7% of deaths)
for each U.S. Census Bureau region.††† To understand how compared with ingestion (15.2%), snorting (13.6%), and
routes of drug use are related to drugs commonly involved in smoking (13.3%) to smoking during July–December 2022
overdose deaths, percentages of overdose deaths with evidence (23.1% of deaths) compared with snorting (16.2%), injec-
of each route were calculated by 6-month period for mutually tion (16.1%), and ingestion (14.5%). During July–December
exclusive categories of drugs detected (IMFs§§§ only, stimu- 2022, most deaths with evidence of smoking (79.7%), snorting
lants only, both IMFs and stimulants, and neither IMFs nor (84.5%), or ingestion (86.5%) had no evidence of injection;
stimulants)¶¶¶ (6). Analyses were performed using SAS soft- among deaths with information on route of use, 81.9% had
ware (version 9.4; SAS Institute). This activity was reviewed evidence of a noninjection route.
by CDC, deemed not research, and was conducted consistent
with applicable federal law and CDC policy.**** Regional Trends
Regional trends were largely consistent with overall trends.
Results The percentage of overdose deaths with evidence of smoking
increased in all U.S. Census Bureau regions (Northeast: 91.0%
Overall Trends
increase, from 8.9% to 17.0%; Midwest: 75.0%, from 12.4%
During January 2020–December 2022, a total of 139,740
to 21.7%; South: 48.0%, from 12.5% to 18.5%; and West:
overdose deaths occurred in 28 jurisdictions; deaths increased
68.9%, from 25.1% to 42.4%) (Figure 2). The percentage of
20.2%, from 21,046 during January–June 2020 to 25,301 dur-
deaths with evidence of snorting increased in three regions
ing July–December 2022. The percentage of deaths with IMFs
(Northeast: 28.2%, from 11.7% to 15.0%; Midwest: 23.0%,
detected increased 8.4% from 71.4% during January–June
from 13.9% to 17.1%; and South: 12.4%, from 14.5% to
2020 to 77.4% during July–December 2022. Evidence of at
16.3%). The percentage with evidence of injection decreased
least one route of drug use was documented in 71,480 (51.2%)
in all regions (Northeast: −21.2%, from 21.2% to 16.7%;
overdose deaths. From January–June 2020 to July–December
Midwest: −36.2%, from 21.8% to 13.9%; South: −27.8%,
2022, the number and percentage of overdose deaths with
from 25.9% to 18.7%; and West: −34.3%, from 19.8% to
evidence of smoking increased 109.1% (from 2,794 to 5,843)
13.0%). By July–December 2022, smoking was the most com-
and 73.7% (from 13.3% to 23.1%), respectively (Figure 1).
monly identified route of use in overdose deaths in the Midwest
The number and percentage of deaths with evidence of snorting
(21.7%) and West (42.4%); injection and smoking were most
increased 43.1% (from 2,858 to 4,090) and 19.1% (from 13.6%
common in the Northeast (16.7% and 17.0%, respectively)
to 16.2%), respectively. In contrast, the number and percentage
and South (18.7% and 18.5%, respectively).
of overdose deaths with evidence of injection decreased 14.6%
(from 4,780 to 4,080) and 29.1% (from 22.7% to 16.1%), Trends by Drugs Detected
respectively, from January–June 2020 to July–December 2022. Among overdose deaths with only IMFs detected
Although the number of deaths with evidence of ingestion (13,107; 9.6%), deaths with both IMFs and stimulants
increased 14.6%, from 3,189 to 3,656, the percentage of such detected (58,754; 43.1%), and deaths with only stimulants
deaths declined 4.6%, from 15.2% to 14.5%. detected (8,525; 6.2%), the percentage with evidence of smok-
†††
ing increased, and the percentage with evidence of injection
U.S. Census Bureau regions were used to stratify jurisdictions into
geographic regions (https://www2.census.gov/geo/pdfs/maps-data/maps/
decreased from January–June 2020 to July–December 2022
reference/us_regdiv.pdf ). Region analysis included eight of nine (Figure 3). For IMFs only, the percentage of overdose deaths
jurisdictions in the Northeast Region, five of 12 jurisdictions in the Midwest with evidence of smoking increased 78.9%, from 10.9% to
Region, nine of 17 jurisdictions in the South Region, and six of
13 jurisdictions in the West Region. 19.5%, whereas the percentage with evidence of injection
§§§ Fentanyl was classified as likely illegally manufactured using toxicology, decreased 41.6%, from 20.9% to 12.2%. Among deaths with
scene, and witness evidence. For the 8.1% of deaths involving fentanyl that both IMFs and stimulants detected, the percentage with evi-
had insufficient evidence for classification as illegal or prescription, fentanyl
was classified as illegal because the majority of fentanyl overdose deaths dence of smoking increased 65.4%, from 17.9% to 29.6%,
involve illegal fentanyl. All fentanyl analogs except alfentanil, remifentanil, whereas the percentage with evidence of injection decreased
and sufentanil, which have legitimate human medical use, were included
as IMFs.
25.5%, from 28.6% to 21.3%. A similar pattern was observed
¶¶¶ Analysis of drugs detected was restricted to decedents with an available among deaths with only stimulants detected (smoking: 29.7%
toxicology report (136,466; 97.7% of deaths with a medical examiner or increase, from 15.5% to 20.1%; injection: 22.5% decrease,
coroner report).
**** 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 from 10.2% to 7.9%). Among deaths with neither IMFs
U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. nor stimulants detected (10,628; 7.8%), the percentage with
125
FIGURE 1. Number and percentage of drug overdose deaths with evidence of selected routes of drug use,*,† by 6-month period of death
(N = 139,740) — State Unintentional Drug Overdose Reporting System, 28 jurisdictions,§,¶ January 2020–December 2022
100
7,000
No. ingestion No. injection No. smoking No. snorting
% Ingestion % Injection % Smoking % Snorting

6,000 25
5,000
20
Percentage of deaths
No. of deaths
4,000
15
3,000
10
2,000
5
1,000
0 0
Jan–Jun 2020 Jul–Dec 2020 Jan–Jun 2021 Jul–Dec 2021 Jan–Jun 2022 Jul–Dec 2022
Period
Abbreviation: SUDORS = State Unintentional Drug Overdose Reporting System.

* Percentages with evidence of other routes (i.e., buccal, sublingual, suppository, or transdermal) (583; 0.4%) are not presented because of small sample sizes; decedents
with drug use via these routes are included in the denominators. In addition, percentages of decedents with no information on route (68,260; 48.8%) are not shown;
these decedents are also included in the denominators.
† Routes of drug use are not mutually exclusive; decedents might have used multiple routes.
§ Alaska, Arizona, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska,
New Hampshire, New Jersey, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia. Illinois
and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the respective state in 2017, per SUDORS funding requirements;
all other jurisdictions reported deaths from the full jurisdiction.
¶ Jurisdictions were included if medical examiner or coroner reports and toxicology reports were available for ≥75% of deaths during January 2020–December 2022.
Analysis was restricted to deaths with an available medical examiner or coroner report (139,740; 95.8% of all deaths).
evidence of smoking did not change, and the percentage with From January–June 2020 to July–December 2022, the num-
evidence of injection decreased 42.2% (11.6% to 6.7%); inges- ber of overdose deaths with evidence of smoking doubled, and
tion was the most common route during July–December 2022 the percentage of deaths with evidence of smoking increased
(39.4% of deaths) and throughout the study period. across all geographic regions. By late 2022, smoking was
the predominant route of use among drug overdose deaths
Discussion overall and in the Midwest and West regions. Increases were
The percentage of drug overdose deaths with evidence of most pronounced when IMFs were detected, with or without
smoking increased sharply in all U.S. regions from 2020 to stimulants. Increases in the number and percentage of deaths
2022, indicating the importance of an updated response. By with evidence of smoking, and the corresponding decrease
late 2022, among decedents with information on route of drug in those with evidence of injection, might be partially driven
use, more than three fourths had evidence of a noninjection by 1) the transition from injecting heroin to smoking IMFs
route, highlighting the diversification of methods through (3,4), 2) increases in deaths co-involving IMFs and stimulants
which they used drugs. that might be smoked†††† (1), and 3) increases in the use of
†††† https://adai.uw.edu/wordpress/wp-content/uploads/SaferSmokingBrief_
2022.pdf
126
FIGURE 2. Percentage of drug overdose deaths with evidence of selected routes of drug use,* by U.S. Census Bureau region† and 6-month
period of death (N = 139,740) — State Unintentional Drug Overdose Reporting System, 28 jurisdictions,§ January 2020–December 2022
A. Northeast (n = 38,580) B. Midwest (n = 30,575)

100 100
45 45
40 40
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
Jan–Jun 2020 Jan–Jun 2021 Jan–Jun 2022 Jan–Jun 2020 Jan–Jun 2021 Jan–Jun 2022
Jul–Dec 2020 Jul–Dec 2021 Jul–Dec 2022 Jul–Dec 2020 Jul–Dec 2021 Jul–Dec 2022
Period Period
C. South (n = 47,723) D. West (n = 22,862)
100 100
45 45
40 40
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
Period Period
* Percentages with evidence of other routes (i.e., buccal, sublingual, suppository, or transdermal) are not presented because of small sample sizes (Panel A [Northeast]:
136, 0.4%; Panel B [Midwest]: 121, 0.4%; Panel C [South]: 223, 0.5%; and Panel D [West]: 103, 0.5%); decedents with drug use via these routes are included in the
denominators. In addition, percentages of decedents with no information on route are not shown (Panel A: 22,541, 58.4%; Panel B: 15,381, 50.3%; Panel C: 22,571,
47.3%; and Panel D: 7,767, 34.0%); these decedents are also included in the denominators.
† Analysis included some, but not all, of the jurisdictions in each U.S. Census Bureau region. Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New
Jersey, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Kansas, Minnesota, Nebraska, and Ohio; South: Delaware, District of Columbia, Georgia, Kentucky,
Maryland, North Carolina, Oklahoma, Virginia, and West Virginia; West: Alaska, Arizona, Colorado, Oregon, Utah, and Washington.
§ Jurisdictions were included if medical examiner or coroner reports and toxicology reports were available for ≥75% of deaths during January 2020–December 2022.
Analysis was restricted to deaths with an available medical examiner or coroner report (139,740; 95.8% of all deaths).
counterfeit pills, which frequently contain IMFs and are often intensify drug effects and increase overdose risk (9). Despite
smoked (7). Motivations for transitioning from injection some risk reduction associated with smoking compared with
to smoking include fewer adverse health effects (e.g., fewer injection (e.g., fewer bloodborne infections), smoking carries
abscesses), reduced cost and stigma, sense of more control over substantial overdose risk because of rapid drug absorption (5,9).
drug quantity consumed per use (e.g., smoking small amounts Nearly 80% of overdose deaths with evidence of smoking had
during a period versus a single injection bolus), and a percep- no evidence of injection; persons who use drugs by smoking but
tion of reduced overdose risk among persons who use drugs do not inject drugs might not use traditional syringe services
(3,5,8). These motivations might also signify lower barriers programs where harm reduction messaging and supplies are
for initiating drug use by smoking, or for transitioning from often provided. In response, some jurisdictions have adapted
ingestion to smoking; compared with ingestion, smoking can harm reduction services to provide safer smoking supplies or
127
FIGURE 3. Percentage of drug overdose deaths with evidence of selected routes of drug use,* by drugs detected†,§,¶,**,†† and 6-month period
of death — State Unintentional Drug Overdose Reporting System, 28 jurisdictions,§§ January 2020–December 2022
A. IMFs only (n = 13,107) B. Stimulants only (n = 8,525)
100 100
45 45
40 40
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
Period Period
C. IMFs and stimulants (n = 58,754) D. Neither IMFs nor stimulants (n = 10,628)
100 100
45 45
40 40
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
Period Period
Abbreviations: IMFs = illegally manufactured fentanyls; SUDORS = State Unintentional Drug Overdose Reporting System.
* Percentages with evidence of other routes (i.e., buccal, sublingual, suppository, or transdermal) are not presented because of small sample sizes (Panel A [IMFs
only]: 23, 0.2%; Panel B [Stimulants only]: 11, 0.1%; Panel C [IMFs and stimulants]: 146, 0.2%; and Panel D [Neither IMFs nor stimulants]: 158, 1.5%); decedents with
drug use via these routes are included in the denominators. In addition, percentages of decedents with no information on route are not shown (Panel A: 6,802, 51.9%;
Panel B: 5,652, 66.3%; Panel C: 25,597, 43.6%; and Panel D: 5,435, 51.1%); these decedents are also included in the denominators.
† Data on drugs detected come from postmortem toxicology reports; among decedents with a medical examiner or coroner report, analysis was further restricted
to decedents with a toxicology report (136,466; 97.7% of decedents with a medical examiner or coroner report).
§ Ethanol and other selected drugs (e.g., naloxone and cotinine) were not considered a drug for this analysis; deaths categorized as IMFs only (Panel A) or stimulant
only (Panel B) might have also had ethanol or these other selected drugs detected.
¶ Deaths with IMFs and stimulants detected (Panel C) could also have other drugs detected (e.g., prescription opioids).
** Deaths with neither IMFs nor stimulants detected primarily had prescription opioids (65.3%) or benzodiazepines (37.3%) detected.
†† Drug categories are not comprehensive; some deaths are excluded because they contain drug combinations that are not presented in the panels (e.g., deaths with
only IMFs and prescription opioids detected).
§§ Alaska, Arizona, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Kansas, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska,
New Hampshire, New Jersey, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington, and West Virginia. Illinois
and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the respective state in 2017, per SUDORS funding requirements;
all other jurisdictions reported deaths from the full jurisdiction.
established health hubs to expand reach to persons using drugs services (e.g., peer outreach and provision of fentanyl test
through noninjection routes.§§§§ In addition, harm reduction strips for testing drug products and naloxone to reverse opioid
overdoses), messaging specific to smoking drugs, and linkage
§§§§ https://www.maricopa.gov/DocumentCenter/View/86245/OUD-SUD- to treatment for substance use disorders can be integrated into
Needs-Assessment-Final-Report?bidId=; https://www.cdph.ca.gov/
Programs/CID/DOA/CDPH%20Document%20Library/HR_Supplies_
other health care delivery (e.g., emergency departments) and
Clearinghouse_Factsheet_FINAL.pdf; https://www.health.ny.gov/diseases/ public safety (e.g., drug diversion) settings.
aids/consumers/prevention/
128
The percentage and number of deaths with evidence of injec-

Summary
tion decreased across regions and drug categories. Observed
decreases might reflect transitions to noninjection routes and
response to public health efforts to reduce injection drug use More than 109,000 drug overdose deaths occurred in the
United States in 2022; nearly 70% involved illegally manufac-
because of its risk for overdose and infectious disease trans- tured fentanyls (IMFs). Data from the western United States
mission (3,4,10). Despite these declines, more than 4,000 suggested a transition from injecting heroin to smoking IMFs.
drug overdose deaths had evidence of injection during July– What is added by this report?
December 2022. Syringe services programs help to engage
From January–June 2020 to July–December 2022, the percent-
persons who use drugs in services (10); sustained efforts to age of overdose deaths with evidence of smoking increased
provide sterile injection supplies, additional harm reduction 73.7%, and the percentage with evidence of injection decreased
tools, and linkage to treatment for substance use disorders, 29.1%; similar changes were observed in all U.S. regions.
including medications for opioid use disorder, are important Changes were most pronounced in deaths with IMFs detected,
for further reduction in the number of overdose deaths from with or without stimulant detection.
injection drug use. Lessons learned from implementing syringe What are the implications for public health practice?
services programs could be applied to other harm reduction Strengthening and expanding public health and harm reduc-
and outreach models to reach more persons who use drugs tion services to address overdose risk with smoking and other
noninjection routes might reduce deaths.
by any route.
Limitations settings for persons using drugs by smoking and other routes.
The findings in this report are subject to at least four limita- These strategies might increase access to lifesaving services for
tions. First, analyses included 28 jurisdictions; results might not persons who use drugs through all routes.
be generalizable to the rest of the United States. Second, for
Acknowledgments
nearly one half of deaths, no information about route of drug
use was available; thus, percentages of deaths with evidence of Jurisdictions participating in CDC’s Overdose Data to Action
each route are underestimated. However, no notable differences (OD2A) and Overdose Data to Action in States (OD2A-States)
by time or demographic characteristics among deaths with and programs and providing data to the State Unintentional Drug
Overdose Reporting System, including state and jurisdictional
without route of drug use information were identified. Third,
health departments, vital records offices, and medical examiner and
percentages of noninjection routes are likely underestimated coroner offices; CDC OD2A and OD2A-States teams, Division of
more than those with injection because evidence of injection Overdose Prevention, National Center for Injury Prevention and
is easier to identify (e.g., syringes) than evidence of other Control, CDC.
routes (e.g., stems and straws can be evidence of snorting or Corresponding author: Lauren J. Tanz, ltanz@cdc.gov.
smoking). Finally, routes could not be linked to the use of a
1Division of Overdose Prevention, National Center for Injury Prevention and
specific drug unless only one drug class was detected. Analyses
Control, CDC; 2Division of HIV Prevention, National Center for HIV, Viral
of single drug classes detected (IMFs only and stimulants only) Hepatitis, STD, and TB Prevention, CDC; 3Oak Ridge Institute for Science
were presented to better link routes to drugs. and Education, Oak Ridge, Tennessee.
All authors have completed and submitted the International
Implications for Public Health Practice Committee of Medical Journal Editors form for disclosure of potential
Routes of drug use have implications for overdose risk, conflicts of interest. No potential conflicts of interest were disclosed.
infectious disease transmission, and harm reduction services
(5). Although unsafe injection drug use practices might be References
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130
Hepatitis A Exposure Response and Outbreak Prevention in a Large

Urban Jail — Los Angeles County, California, May–July 2023
Nazia S. Qureshi, MPH1; Alma J. Villatoro, MPH1; Ngoc Dung T. Tran, PharmD1; Sulma J. Herrera, MD1; Stephen P. Judge, MD1,2;
Ling Fang, MS, MHA1; Sean O. Henderson, MD1; Kristy A. Stanley, MD1
Abstract care at LACJ Urgent Care, reporting that he had not eaten in
Correctional settings provide a high-risk environment for 4 days because of abdominal pain, nausea, and vomiting, and
hepatitis A transmission because of the high proportion of that he had jaundice. LACJ Urgent Care staff members noted
homelessness and injection drug use among persons who jaundice of the skin and that the patient had been incarcerated
are incarcerated. On May 30, 2023, Los Angeles County on April 27, 2023, with self-reported homelessness, injection
Department of Public Health informed the Communicable drug use, and alcohol use disorder on the intake history. He had
Disease Surveillance and Control (CDSC) unit of the Los been on a Clinical Institute Withdrawal Assessment protocol
Angeles County Jail system that a symptomatic incarcerated beginning April 28, 2023, and was transferred to Los Angeles
person had received a positive test result for acute hepatitis A. General Medical Center (LAGMC) from LACJ Urgent Care
Upon learning the next day that the patient was a food handler, on May 28 for emergency evaluation. He remained there until
CDSC staff members identified 5,830 potential contacts of June 2. Liver enzymes were elevated, and antihepatitis A virus
the index patient, 1,702 of whom had been released from the (HAV) immunoglobulin (Ig) M was reactive. A stool sample
jail. During June 1–12, a total of 2,766 contacts who did not collected on May 28 was positive for hepatitis A by polymerase
have a documented history of hepatitis A serology or vaccina- chain reaction on June 2. The patient had no documented
tion that could be confirmed from the electronic health record history of hepatitis A immunity (vaccination or serology)
or state immunization registry were identified. These persons in the existing electronic health records or in the statewide
were offered hepatitis A vaccination as postexposure prophy- immunization registry.*
laxis; 1,510 (54.6%) accepted vaccination. Contacts who were
food handlers without confirmed evidence of immunity and Exposure Determination
who declined vaccination were removed from food-handling On May 30, CHS Communicable Disease Surveillance and
duties for the duration of their potential incubation period. Control staff members were informed of the reactive anti-HAV
No additional cases were identified. Identifying contacts IgM test result and formulated a plan to provide postexposure
promptly and using immunization and serology records to prophylactic hepatitis A vaccination to persons who had shared
ensure rapid delivery of postexposure prophylactic vaccine can housing with the index patient during the infectious period.†
help prevent hepatitis A transmission during exposures among Based on the reported symptoms of the index patient, the
incarcerated populations. index patient’s infectious period was defined as May 9–28,
with the potential incubation period of the index patient’s
Investigation and Results contacts estimated to end on July 17.§ On May 31, the Acute
The Los Angeles County Jail system (LACJ), the largest in the Communicable Disease Control (ACDC) branch of the Los
United States, consists of six facilities. The average number of Angeles County Department of Public Health informed CHS
bookings per year is 53,000, and daily census is approximately that they had interviewed the patient earlier the same day dur-
13,330 persons. Correctional Health Services (CHS), a depart- ing his inpatient stay at LAGMC, and he had been assigned to
ment within the Los Angeles County Department of Health food preparation in the Men’s Central Jail kitchen. The contact
Services, provides health care for the incarcerated population. investigation was expanded to account for both shared housing
and food handling after the interview with the index patient.
Index Patient
On May 25, 2023, an incarcerated man aged 41 years housed * Since 2000, all persons incarcerated within LACJ have electronic health records.
As of September 2022, CHS began using the same electronic health records
in the Los Angeles County Men’s Central Jail sought care at a system as the Los Angeles County Department of Health Services.
clinic and reported vomiting for 2 days (Figure 1). The clinic † Although CHS and LAGMC share the same electronic health records platform,
documented that he received antiemetics and antacids and that the electronic health record identifiers used by the two facilities are different and
led to reliance on external notification of the reactive IgM anti-HAV test result.
he reported feeling better later that day. On May 28, he sought § https://www.bop.gov/resources/pdfs/hep_a_timeline_calc.xlsx
131
FIGURE 1. Timeline of hepatitis A exposure discovery and response by Correctional Health Services Communicable Disease and Surveillance
Unit staff members — Los Angeles County, California, April–July 2023
Index patient Index Index Local public Index Jail State Mass Incubation
is incarcerated, patient patient has health patient is personnel laboratory vaccination period for
reports a reports worsening department identified initiate confirms campaign is index
history of vomiting symptoms, informs jail as a food hepatitis A hepatitis A completed. patient
substance use and is including of index handler. mass infection ends. No
disorder and prescribed jaundice, patient. Jail vaccination with stool further
alcohol antiemetics and is sent Infectious personnel campaign, sample cases of
withdrawal, and to hospital, period is identify all prioritizing polymerase acute
and is placed antacids. which defined. possible contacts chain hepatitis A
on protocol for confirms contacts. without reaction are
alcohol acute known test. reported or
withdrawal. infection. vaccination identified.
history or
immunity.
April 27 May 25 May 28 May 30 May 31 June 1 June 2 June 12 July 17

2023
Public Health Response offered vaccine and 1,510 (54.6%) agreed to receive it. Persons
CHS Communicable Disease Surveillance and Control who initially declined vaccination were offered a second oppor-
staff members identified and shared with ACDC a list of tunity to receive vaccine. Incarcerated kitchen workers with
5,830 persons who had been housed in Men’s Central Jail undocumented vaccination history or undocumented serology
during the defined infectious period, 1,702 of whom had who declined vaccination were removed from kitchen duties
been released from the jail. From the list of 4,128 contacts in until the end of their potential incubation period.
custody, electronic health records and the state immunization Los Angeles County Men’s Central Jail health care and custo-
registry were reviewed to remove persons with documented dial employees who were in contact with the index patient during
positive hepatitis A serology or vaccination. (Figure 2). This his infectious period were notified of possible exposure and were
activity was reviewed and approved by the Los Angeles County offered hepatitis A vaccination through a combination of CHS
Public Health, Ambulatory Care Network, and Health Services employee health clinic and Los Angeles County Department of
Administration Institutional Review Board.¶ Public Health immunization services. Daily CHS communicable
disease surveillance laboratory reports that identified reactive
Vaccination anti-HAV IgM results were enhanced by creating an additional
An initial hepatitis A vaccine supply was procured from the report that noted hepatitis A or any related signs or symptoms
Los Angeles County Department of Public Health (226 doses), as a reason for emergency hospital transfer. As of October 16,
and CHS purchased additional vaccine (1,500 doses). Because 2023, no additional cases of acute hepatitis A had been reported
of the initial limited supply, CHS began offering vaccine on or identified in any of the LACJ facilities.
June 1 only to persons located in the same housing units as
Discussion
the index patient, and then, on June 2 and June 3, to those
in the additional Men’s Central Jail kitchen incarcerated Since 2016, person-to-person outbreaks of hepatitis A in
worker dormitories. Upon acquisition of additional vaccine, the United States have been increasingly occurring among
vaccination of the remaining contacts (i.e., persons who were persons who use drugs, those who experience homelessness,
incarcerated who had been in Men’s Central Jail during the and men who have sex with men (1). The risk for hepatitis A
infectious period and who were not kitchen workers) began transmission is elevated in jails because they house a dispro-
on June 4. During June 1–12, a total of 2,766 persons were portionate number of persons in these populations, in addition
to their crowded living conditions and transient population.
¶ 45 C.F.R. part 46.101(c); 21 C.F.R. part 56.
132
FIGURE 2. Identification of contacts at Los Angeles County Men’s Central Jail who were eligible to receive postexposure prophylaxis hepatitis A
vaccine — Los Angeles County, California, May–July 2023
5,830 contacts identified on May 31,

2023, who had been housed in
LAC MCJ during the infectious period
1,702 contacts released; information 4,128 contacts

provided to public health department remained incarcerated
1,362 contacts with 2,766 contacts with

verified reactive hepatitis A serology or no verifiable hepatitis A serology or
vaccination records vaccination records
1,256 contacts declined 1,510 contacts received

hepatitis A vaccine hepatitis A vaccine
Abbreviations: LAC = Los Angeles County; MCJ = Men’s Central Jail.
Identification of an acute hepatitis A case in a jail, therefore, and B vaccination records in the state immunization registry
requires a prompt response and contact identification (2). as well as hepatitis A and B vaccination and serology records
CHS was able to implement a timely infection control in the electronic health record. These records helped focus
response by identifying all possible incarcerated contacts and vaccination efforts on persons who were not immune and offer
initiating a mass vaccination response within 48 hours of postexposure prophylaxis to those identified as eligible for receipt
notification of the index case (Figure 1). Mass vaccination within 2 weeks of identifying the index patient. The prompt
campaigns for time-sensitive responses in jail settings can be vaccine rollout likely helped reduce transmission and prevent an
challenging because they involve a large number of persons, as outbreak among the LACJ population, and the enhanced sur-
well as logistic issues, and obstacles to timely vaccine procure- veillance, which included the monitoring of emergency hospital
ment. During 2007–2010, hepatitis vaccination campaigns transfers made because of suspicion of acute hepatitis A, helped
were conducted at LACJ among men who have sex with men identify possible secondary cases or clusters needing further
(3) and during 2017–2019 among the entire LACJ popula- investigation. Because of the range of the hepatitis A incuba-
tion (CHS, unpublished data, 2019) in response to the 2017 tion period (15–50 days) and the date of incarceration of
hepatitis A outbreak in San Diego (4). the index patient, whether his infection was acquired before
An effort to improve compliance with the mandatory report- or during incarceration is uncertain. The index patient had
ing to the California immunization registry led to steps being reported risk factors at the time of intake (i.e., homelessness
taken to improve the quality and completeness of hepatitis A and injection drug use) for which hepatitis A vaccination is
133
setting to minimize risk for transmission and help prevent an

Summary
outbreak. Having relevant laboratory results for reportable
communicable diseases consistently and seamlessly communi-
Risk for hepatitis A transmission in correctional settings is high cated electronically across different health systems with mutual
because of the high proportion of homelessness and injection
drug use among persons who are incarcerated.
patients and using serology and vaccination records from
electronic health records and state immunization registries can
What is added by this report?
facilitate and optimize the response to a potential exposure by
On May 30, 2023, the Los Angeles County Jail system was
ensuring the timely administration of postexposure prophylaxis
notified that an incarcerated person had received a positive
hepatitis A test result. Using electronic health records and the to those who are at greatest risk.
state immunization registry, investigators identified persons
Acknowledgments
eligible for hepatitis A vaccination, and a vaccination response
was initiated within 48 hours: 2,766 persons were offered Correctional Health Services vaccination team; Mark A. Malek.
vaccine, and 1,510 (54.6%) agreed to receive it. No additional Corresponding author: Nazia S. Qureshi, nqureshi@dhs.lacounty.gov.
cases were identified.
1Integrated Correctional Health Services-Los Angeles County Department of
What are the implications for public health practice?
Health Services, Los Angeles, California; 2Division of Infectious Diseases,
Identifying contacts promptly and using immunization and Harbor-UCLA Medical Center, Torrance, California.
serology records to ensure rapid delivery of postexposure
prophylactic vaccine can help prevent hepatitis A transmission
during exposures among incarcerated populations. Committee of Medical Journal Editors form for disclosure of potential
conflicts of interest. No potential conflicts of interest were disclosed.
recommended (1,2). The correctional environment presents References

a unique opportunity to reduce hepatitis A transmission and 1. CDC. Outbreaks of hepatitis A across the United States. Atlanta, GA: US
disease through vaccination (5–7); accordingly, CHS might Department of Health and Human Services, CDC; 2023. https://www.
consider a more comprehensive routine vaccination strategy, cdc.gov/hepatitis/outbreaks/2017March-HepatitisA.htm
2. Federal Bureau of Prisons. Hepatitis A: clinical guidance. Washington,
including offering vaccination at intake. DC: United States Department of Justice, Federal Bureau of Prisons;
2019. https://www.bop.gov/resources/pdfs/hepatitis_a_cpg_112019.pdf
Implications for Public Health Practice 3. Costumbrado J, Stirland A, Cox G, et al. Implementation of a hepatitis A/B
vaccination program using an accelerated schedule among high-risk
The infection control response initially included a plan to inmates, Los Angeles County Jail, 2007–2010. Vaccine 2012;30:6878–82.
offer hepatitis A vaccine and Ig to persons who were immu- PMID:22989688 https://doi.org/10.1016/j.vaccine.2012.09.006
nocompromised, aged >60 years, or both (8); however, Ig 4. San Diego County Health & Human Services Agency. 2017 hepatitis A
outbreak. San Diego, CA: San Diego County Health & Human Services
could not be obtained within the indicated time frame because Agency; 2017. https://www.sandiegocounty.gov/content/sdc/hhsa/
of logistic issues. Future infection control planning at CHS programs/phs/community_epidemiology/dc/Hepatitis_A/outbreak.html
involves maintaining a supply of hepatitis A Ig for emergency 5. Gondles EF. A call to immunize the correctional population for hepatitis A
use in case of an exposure or outbreak. A major limitation of and B. Am J Med 2005;118(Suppl 10A):84–9. PMID:16271547 https://
doi.org/10.1016/j.amjmed.2005.07.025
the CHS hepatitis A surveillance process was that reactive IgM 6. Vong S, Fiore AE, Haight DO, et al. Vaccination in the county jail as a
anti-HAV laboratory results from LAGMC did not appear in strategy to reach high risk adults during a community-based hepatitis A
CHS communicable disease laboratory reports because of the outbreak among methamphetamine drug users. Vaccine 2005;23:1021–8.
PMID:15620475 https://doi.org/10.1016/j.vaccine.2004.07.038
different electronic health record identifiers used by the two 7. Hagan LM, Montgomery MP, Lauro PL, et al. Recent incarceration
facilities. A modified communicable disease surveillance report among individuals infected with hepatitis A virus during person-
that retrieves reactive IgM anti-HAV results from LAGMC to-person community outbreaks, United States, 2016–2020. Public
Health Rep 2023;138:619–24. PMID:35856418 https://doi.
conducted on CHS patients that contains CHS-specific iden- org/10.1177/00333549221108413
tifiers was created after the response to help prevent delays 8. Gounder P, Balter S. Rx for prevention: clinical recognition and
in identifying cases and planning for exposure response and management of hepatitis A: preventing outbreaks in Los Angeles County.
mitigation. This exposure response highlights the importance Los Angeles, CA: County of Los Angeles Public Health; 2019. http://
rx.ph.lacounty.gov/RxHepA1119
of initiating a rapid response to hepatitis A exposure in a jail
134
Notes from the Field
Long COVID Prevalence Among Adults — United deemed not research, and was conducted consistent with
States, 2022 applicable federal law and CDC policy.§
Nicole D. Ford, PhD1; Abraham Agedew1,2; Alexandra F. Dalton, PhD1;
Jordan Singleton, MD1,3; Cria G. Perrine, PhD1; Sharon Saydah, PhD1 Preliminary Conclusions and Analysis
Nationally, 6.4% of noninstitutionalized U.S. adults reported
ever having experienced Long COVID (95% CI = 6.2%–6.5%)
Introduction (Supplementary Table, https://stacks.cdc.gov/view/
Post-COVID conditions, also known as Long COVID, cdc/147385). The weighted age- and sex-standardized preva-
encompass a range of health problems* that emerge, persist, lence ranged from 1.9% (95% CI = 0.9%–4.1%) for the U.S.
or recur following acute COVID-19 illness, including fatigue, Virgin Islands to 10.6% (95% CI = 9.5%–11.8%) for West
respiratory symptoms, and neurologic symptoms. In 2022, 6.9% Virginia (Figure) and exceeded 8.8% (the highest prevalence
of U.S. adults reported ever experiencing Long COVID (1). quintile cutoff ) in seven states. Prevalences tended to be lower
State- and territory-specific surveillance estimates can guide in New England and the Pacific and higher in the South,
public health action to mitigate the impact of Long COVID; Midwest, and West.¶
however, few published data are available. The Association of This study was subject to some limitations. BRFSS did not
State and Territorial Health Officials (2) and the Council of capture treatment during acute COVID infection, time since
State and Territorial Epidemiologists (3) have published reports COVID-19 illness, or duration or severity of symptoms, which
outlining gaps and needs in Long COVID surveillance for state, could influence the reported prevalence of Long COVID. In
tribal, local, and territorial public health agencies. addition, information about COVID-19 vaccination was only
available for a subset of jurisdictions and is not included in
Investigation and Outcomes this report.
CDC analyzed data from noninstitutionalized U.S. adults
aged ≥18 years participating in the 2022 Behavioral Risk § 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
Factor Surveillance System (BRFSS), a population-based Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
¶ https://www.cdc.gov/nchs/hus/sources-definitions/geographic-region.htm
cross-sectional survey (4). Respondents were sampled using
random digit dialing of both landline and cellular telephones.
Self-reported age, sex, previous COVID-19 diagnosis,† and FIGURE. Prevalence of reported experience of Long COVID among
ever having experienced Long COVID were ascertained via adults aged ≥18 years, by jurisdiction — Behavioral Risk Factor
Surveillance System, United States, 2022
telephone interview. Long COVID was defined as the self-
report of any symptoms lasting ≥3 months that were not
present before having COVID-19. CDC estimated weighted
age- and sex-standardized prevalence with a 95% CI of ever
having experienced Long COVID among all adults nation-
ally, irrespective of COVID-19 history, in the 50 states, the
District of Columbia, Guam, Puerto Rico, and the U.S. Virgin
Islands. Estimates were standardized to the 2020 U.S. Census DC
Bureau population of noninstitutionalized, civilian adults. Sex- GU
PR
specific weights by age group were applied for persons aged USVI
18–44, 45–64, and ≥65 years. Analyses were conducted using
SAS-callable SUDAAN (version 9.4; RTI International) and
account for complex survey design. Prevalence estimates were
divided into quintiles. This activity was reviewed by CDC, 8.9%–10.6%
7.2%–8.8%
5.4%–7.1%
* https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html 3.7%–5.3%
† Respondents were classified as having previously had COVID-19 if they
1.9%–3.6%
responded affirmatively to the question, “Has a doctor, nurse, or other health
professional ever told you that you tested positive for COVID-19?” or if they
reported a positive test result based on a home test. Abbreviations: DC = District of Columbia; GU = Guam; PR = Puerto Rico;
USVI = U.S. Virgin Islands.
135
Corresponding author: Nicole D. Ford, yex9@cdc.gov.

Summary
1Coronavirus and Other Respiratory Viruses Division, National Center for
Immunization and Respiratory Diseases, CDC; 2General Dynamics Information
Long COVID encompasses a range of health problems that Technology, Falls Church, Virginia; 3Epidemic Intelligence Service, CDC.
emerge, persist, or recur following acute COVID-19 illness.
What is added by this report? Committee of Medical Journal Editors form for disclosure of potential
Age- and sex-standardized prevalence of reporting ever having conflicts of interest. No potential conflicts of interest were disclosed.
experienced Long COVID among Behavioral Risk Factor
Surveillance System survey respondents in U.S. states and References
territories ranged from 1.9% (95% CI = 0.9%–4.1%) in the U.S. 1. Adjaye-Gbewonyo D, Vahratian A, Perrine CG, Bertolli J. Long COVID
Virgin Islands to 10.6% (95% CI = 9.5%–11.8%) in West Virginia; in adults: United States, 2022. NCHS Data Brief No. 480. Atlanta, GA:
prevalence of Long COVID exceeded 8.8% in seven states. US Department of Health and Human Services, National Center for
What are the implications for public health practice? Health Statistics, CDC; 2023. https://stacks.cdc.gov/view/cdc/132417
2. Plescia M. From the chief medical officer: leadership considerations for
Ongoing assessment of jurisdiction-specific prevalence of Long COVID [Blog]. Arlington, VA: Association of State and Territorial
Long COVID could inform policy, planning, or programming to Health Officials; 2023. https://www.astho.org/communications/blog/
support U.S. adults experiencing Long COVID. cmo-leadership-considerations-for-long-covid/
3. Council of State and Territorial Epidemiologists. State, tribal, local, and
territorial public health agency approaches to Long COVID-19/post
The findings in this report address an important data gap COVID-19 condition surveillance: lessons learned, gaps, and needs; 2023.
in knowledge about the prevalence of Long COVID. Given Atlanta, GA: Council of State and Territorial Epidemiologists; 2023.
https://preparedness.cste.org/wp-content/uploads/2023/09/CSTE-STLT-
the increased health care needs among persons experiencing Long-COVID-Surveillance-August-2023.pdf
Long COVID (5), ongoing assessment of state- and territory- 4. CDC. Behavioral Risk Factor Surveillance System: 2022 BRFSS survey
level prevalence data could guide policy, planning, or program- data and documentation: Atlanta, GA: US Department of Health and
ming. State-level estimates might also help identify geographic Human Services, CDC; 2023. https://www.cdc.gov/brfss/annual_data/
annual_2022.html
disparities in Long COVID across the United States that could 5. Tartof SY, Malden DE, Liu IA, et al. Health care utilization in the
guide interventions to promote health equity. 6 months following SARS-CoV-2 infection. JAMA Netw Open
2022;5:e2225657. PMID:35960522 https://doi.org/10.1001/
jamanetworkopen.2022.25657
136
QuickStats
FROM THE NATIONAL CENTER FOR HEALTH STATISTICS
Percentage* of Adults Aged ≥18 Years Who Were Advised During the Past
12 Months by a Doctor or Other Health Professional to Increase Their Amount
of Physical Activity or Exercise,† by Age Group and Sex — National Health
Interview Survey, United States, 2022§
100
50 Men
Women
40
Percentage
30
20
10
0
Total 18–34 35–49 50–64 ≥65
Age group, yrs
* With 95% CIs indicated by error bars.

† Based on a response of “yes” to the survey question, “During the past 12 months, has a doctor or other health
professional advised you to increase the amount of physical activity or exercise you get?”
§ Estimates are based on household interviews of a sample of the civilian, noninstitutionalized U.S. population.
In 2022, among adults aged ≥18 years, women were more likely than men (22.9% versus 17.8%) to be advised during the past
12 months by a doctor or other health professional to increase their amount of physical activity or exercise. Percentages were
higher among women than men in all age groups: 16.2% versus 9.5% among adults aged 18–34 years, 23.5% versus 18.6%
among those aged 35–49 years, 27.5% versus 23.3% among those aged 50–64 years, and 25.3% versus 22.1% among those aged
≥65 years. Among both men and women, the percentage of those who were advised during the past 12 months by a doctor or
other health professional to increase their amount of physical activity or exercise was lowest among those aged 18–34 years.
Source: National Center for Health Statistics, National Health Interview Survey, 2022. https://www.cdc.gov/nchs/nhis.htm
Reported by: Nazik Elgaddal, MS, nelgaddal@cdc.gov.
137
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Morbidity and Mortality Weekly Report

Weekly / Vol. 73 / No. 6 February 15, 2024

Surveillance for Lyme Disease After Implementation of a Revised

Abstract relies almost exclusively on serologic testing for antibodies to

U.S. Department of Health and Human Services

MMWR Editorial and Production Staff (Weekly)

U.S. total 37,118§§ 62,551 68.5 11.2 18.9 7.7

Ratio of 2022 incidence to 2017–2019 incidence

45 Males 2017–2019 Males

8 Illness onset 2017–2019

Abstract to smoking IMFs; however, limited data exist on recent changes

% Ingestion % Injection % Smoking % Snorting

Abbreviation: SUDORS = State Unintentional Drug Overdose Reporting System.

A. Northeast (n = 38,580) B. Midwest (n = 30,575)

% Ingestion % Injection % Smoking % Snorting

The percentage and number of deaths with evidence of injec-

Hepatitis A Exposure Response and Outbreak Prevention in a Large

April 27 May 25 May 28 May 30 May 31 June 1 June 2 June 12 July 17

5,830 contacts identified on May 31,

1,702 contacts released; information 4,128 contacts

1,362 contacts with 2,766 contacts with

1,256 contacts declined 1,510 contacts received

Abbreviations: LAC = Los Angeles County; MCJ = Men’s Central Jail.

setting to minimize risk for transmission and help prevent an

recommended (1,2). The correctional environment presents References

Notes from the Field

Corresponding author: Nicole D. Ford, yex9@cdc.gov.

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

* With 95% CIs indicated by error bars.

ISSN: 0149-2195 (Print)

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